35 y old male came to opd with fever
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan.
Name: P.Nikitha
Roll no: 102
A 35 year male auto driver by occupation came to opd on 16th june with chief complaints of
fever since 15 days
vomiting since 10 days
History of presenting illness:-
Patient was apparently asymptomatic 15 days ago then he developed fever which is continuous associated with back pain, no chills and rigors.
For this he visited local RMP and took medications by which fever got resolved
5 days later he developed vomitings, 6 to 7 times a day, non bilious, non projectile, food particles as contents, non bloody
This time patient went to a hospital and he was diagnosed with dengue fever and pulmonary oedema?
Past history:
No history of similar complaints
No history of any blood transfusions
N/k/c/o DM, HTN, CVD, Asthama, Epilepsy, Thyroid problems
Personal history:
Mixed diet
Adequate sleep
Normal bowel and bladder movements
No addictions
No allergies
Family history: Not significant
General examination:
Patient is conscious, coherent and cooperative, well oriented to time, place and person
No pallor,cyanosis ,clubbing,lymphadenopathy and pedal edema
Has icterus and yellowish discolouration of palms
Vitals:
Pulse: 72 beats/min
Bp: 124/80 mm Hg
Temperature: afebrile
RR: 16 cycles/min
Systemic examination:
CVS- S1 S2 heard no murmurs
CNS- No focal neurological deficit
RS- Normal vesicular sounds heard
Provisional diagnosis:
Fever with thrombocytopenia Dengue?
Investigations
Treatment:
15 /6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab udiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)syp hepamerz 10 mL iv
6. tab dolo 650 mg sos
16/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab udiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)syp hepamerz 10 mL iv
6. tab dolo 650 mg sos
17/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6. tab dolo 650 mg sos
7. syp hepamerz 10 mL iv
8. Syp lactulose 15 mL bd
18/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6. tab dolo 650 mg sos
7. syp hepamerz 10 mL iv
8. Syp lactulose 15 mL bd
19/6/23
Rx
1)IV fluids Ns 75ml /hr
2)Inj zofer 4mg iv/tid
3)tab odiliv 300 mg
4)inj optineuron 10 mp 1 ONS/iv
5)inj doxy 100mg po/BD
6. tab dolo 650 mg sos
7. syp hepamerz 10 mL iv
8. Syp lactulose 15 mL bd
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